ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 45 : Caring for Clients With Disorders of the Upper Gastrointestinal Tract Questions
Question 1 of 5
The nurse has placed a feeding tube for a client with a gastroesophageal disorder. What recommendation(s) should the nurse follow to confirm proper placement of the tube? Select all that apply.
Correct Answer: A,B,D,E,F
Rationale: The nurse should observe for respiratory distress, measure the pH of feeding tube aspirates, monitor the aspirate for a sudden change in the amount, and mark the tube at the exit site after radiographic confirmation and then use the marker to ensure that the correct location is maintained during use. Auscultation should not be used to determine location, because this is not a valid way to confirm tube placement.
Question 2 of 5
The nurse fills a tube feeding bag with two 8-oz cans of commercially prepared formula. The client is to receive the formula at 80 mL/hour via continuous gastrostomy feeding tube and pump. How many hours will this bag of formula run before becoming empty? Record your answer using a whole number.
Correct Answer: A
Rationale:
Step 1: 2 * 8 oz = 16 oz
Step 2: 1 oz : 30 mL :: 16 oz : X mL X = 480 mL
Step 3: 480 mL / 80 mL = 6 hours
Question 3 of 5
The nurse is managing the care of a client needing gastrointestinal suction and decompression with a Levin tube. Place the steps of initiating suction and decompression in the order the nurse should perform them.
Correct Answer: B,D,A,C
Rationale: The nurse should locate the suction source, usually a wall outlet or portable machine. The nurse should then adjust the suction level on the wall outlet or portable machine to provide the amount and frequency of suction specified by the primary provider. The nurse should select intermittent high, low, or continuous suction when using a Salem sump tube; the nurse should select low intermittent suction when using a Levin tube because the single lumen may adhere to the lining of the stomach during continuous suction (if the tube is used only to obtain specimens for diagnostic purposes, manual suction may be achieved by attaching a syringe to the end of the tube and drawing back on the plunger). Finally, the nurse should insert the gastric decompression tube in accordance with accepted standards and connect it to the suction.
Question 4 of 5
A client who has recovered from anesthesia following oral surgery for lip cancer is experiencing difficulty breathing deeply and coughing up secretions. Which measure will help ease the client's discomfort?
Correct Answer: A
Rationale: It is essential to position the client with the head of the bed elevated because it is easier for the client to breathe deeply and cough up secretions after recovering from the anesthetic. Positioning the client flat either on the abdomen or side with the head turned to the side will facilitate drainage from the mouth until the client has recovered from anesthesia. A tracheostomy tray is kept by the bed for respiratory distress or airway obstruction. When mouth irrigation is carried out, the nurse should turn the client's head to the side to allow the solution to run in gently and flow out.
Question 5 of 5
An older adult client presents with a complaint of 10-lb weight loss over the past month. Which assessment finding is most important in determining the care of this client?
Correct Answer: C
Rationale: Decreased appetite may be a result of diminished oxygenation to the appetite centers of the brain. With a history of chronic obstructive pulmonary disease, oxygen deprivation may be occurring, and this is a starting assessment for this client. Seasonal allergies can aggravate breathing difficulties but are not as significant as COPD. Removal of the gallbladder is not indicated in current weight loss issues. Osteoarthritis may make it more difficult for the client to shop for food but not is as significant as oxygen deprivation.